Running in the Never-ending Race Against Healthcare Fraud (Strategic Focus)

Published by: Datamonitor

Published: Sep. 4, 2009 - 15 Pages

Table of Contents

Overview

Catalyst

Summary

Key Messages

In healthcare fraud prevention, public sector leads the charge

Retrospective, prospective and real-time solutions should be used in tandem

Collaboration between public and private payers is key

Table of Contents

Table of figures

Market Opportunity

Detecting healthcare fraud is a never-ending 'Red Queen's race'

Both private and public payers are now shining a spotlight on healthcare fraud

In an economic recession, payers are unable to pass higher costs onto patients

Government led initiatives against fraud impact the private sector as well

As providers move to EHRs and ICD-10, opportunities for fraud will likely increase

Yet tackling healthcare fraud is still a sensitive subject that is not taken seriously

Within a payer organization, fraud is a politically difficult topic to broach

Payers do not want to alienate their provider networks

While committing healthcare fraud may be a laughing matter, fighting fraud is not

Technology Evolution

Old and new tools are being used to fight fraud

Healthcare fraud detection is slowly moving closer to real time

Retrospective analysis of claims data will continue to play a role in catching fraud

The use of prospective analysis is growing and the benefits are clear

Regional health information organizations may increase collaboration between payers

On-demand solutions are the easiest and most cost effective

Educating doctors on good billing practices is a must

Looking to the future, EHRs will change billing processes and, in turn, fraud detection

Customer Impact: Recommendations to Healthcare Payers

Be open to increased collaboration with other payers

Incorporate patient inquiries as a part of the fraud detection process

If financially possible, consider using more than one solution

Go to Market: Recommendations to Technology Vendors

IT vendors need to start focusing on medical identity solutions as well

Vendors must take market education to a new level, the C-level

It goes without saying, but technology companies should continue developing new tools

APPENDIX

Abbreviations

Methodology

Further reading

Ask the analyst

Datamonitor consulting

Disclaimer

List of Figures

Figure 1: The number of stakeholders involved in the claims process makes it vulnerable to fraud

Figure 2: Potential for fraud centers around the provider

Figure 3: On the surface, claims processing seems to be straightforward

Figure 4: A comparison of real-time, prospective and retrospective analysis

Figure 5: Claim submission process will be streamlined in the future due to EHRs

Abstract

• Provides an overview of market trends
• Highlights priorities for solution development
• Analyzes the pricing models of fraud solutions

• Understand how the Obama administration is impacting healthcare fraud
• Identify the near and mid-term threats to fraud detection

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